Knowledge About Alzheimer’s Disease in Saudi Arabia

Background Alzheimer’s disease (AD) is the most common neurodegenerative dementia which constitutes a major healthcare problem globally. This study aimed to assess the pattern and determinants of knowledge about AD in Saudi Arabia. Methodology In this cross-sectional study, information was collected from 286 participants using a validated questionnaire on seven subdomains of knowledge about AD. SPSS (IBM Corp., Armonk, NY, USA) was used for data analysis. Different tests of significance such as the chi-square test and principal component factor analyses were employed. The level of significance was set at 0.05. Results The 25 questions on knowledge, attitudes, and practice about AD had a high Cronbach’s alpha (0.911). All scores on the seven subdomains of knowledge, attitudes, and practice about AD were significantly correlated with each other (p < 0.05). The knowledge of the population about AD was very low, with the majority of the correct responses for questions on the different subdomains of knowledge about AD ranging from 10% to 67% (76% of the answers were below 50% correct answers). Females and smokers had higher scores on most subdomains compared to males and non-smokers (p < 0.05). Conclusions Knowledge of the population about AD is very low. As the subdomains of knowledge on AD are correlated, healthcare professionals should implement health education programs on AD to increase the knowledge of the population regarding the course, symptoms, risk factors, treatment and management, and caregiving and reveal their association with the impact of AD on the health of affected individuals.


Introduction
Alzheimer's disease (AD), the most common neurodegenerative dementia, is characterized by the formation of amyloid plaques in the brain, loss of neuronal tissue, and the appearance of neurofibrillary tangles inside neurons, with subsequent brain atrophy, ongoing neurodegeneration, and cognitive impairment [1,2].AD is significantly associated with increased age and family history and may occur due to traumatic brain damage [3][4][5][6][7].
Disorientation, cognitive decline, generalized confusion, and memory impairment are the main clinical symptoms of AD [8][9][10].Individuals with AD may show warning symptoms such as sleep disturbance, mood changes, personality changes, and language difficulties [11,12].AD occurs more commonly in the elderly [5].Pathological lesions are usually preceded by oxidative stress [13,14].AD is significantly more common in individuals whose jobs entail lower mental demands and higher physical demands [15,16].Chronic diseases associated with the incidence and worsening of AD include diabetes mellitus, renal disease, cardiovascular disease, and high cholesterol [17].Depression is also associated with the occurrence of AD, with both adversely affecting the quality of life of the patients [18].Dementia is a prevailing neurodegenerative disease globally, with an incidence of 6.4% in Saudi Arabia [19].Women after the ages of 80-85 years are at a greater risk of AD compared to men.This increased risk is related to the depletion of endogenous estrogen in the menopausal period [14].Cigarette smoking increases the risk of AD [17,18].This study aimed to explore the association of different sociodemographic characteristics with the knowledge about AD in a population from Saudi Arabia.

Materials And Methods
This cross-sectional study employed a non-probability convenient sampling technique.Data were collected via online Google Forms distributed to individuals from Saudi Arabia.The sample size was determined using G*power software using an α of 0.05, power of 0.95, effect size of 0.3, and degree of freedom of 5.The minimal sample size required was 277.All 286 individuals who received the form, filled it, and sent it back were included in this study.For data collection, a predesigned questionnaire was used which included information on the sociodemographic and clinical characteristics of the participants.The validated Polish Alzheimer's Disease Knowledge Scale (ADKS) questionnaire was used [19] to describe seven subdomains, namely, risk factors; evaluation and diagnosis; symptoms; course; life effect, caregiving; and therapy and management of AD (Appendices).Each question was given three codes as follows: 3 for true, 2 for false, and 1 for do not know.The score for each domain was calculated using a simple additive method [20,21].

Statistical analysis
Data were analyzed using the SPSS software (IBM Corp., Armonk, NY, USA).The chi-square test of significance, Student's t-test, and analysis of variance were used.The multifactorial principal component factor analysis was employed, and variables with weights of 0.5 or more were considered significantly associated with the factor.Only one factor proved to be significantly associated with most of the variables.The level of significance for the present study was set at 0.05.

Ethical considerations
This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Ibn Sina National College for Medical Studies (approval number: H-07-09062021; approval date: 09.06.2021).

Results
The present study included 286 participants (53.1% males and 46.9% females) to assess the knowledge of the population about AD using the Polish ADKS questionnaire [19].The 25 questions of ADKS about the seven domains on clinical aspects and management of AD used in the present study were highly reliable, with a Cronbach's alpha of 0.911.The percentage of correct answers is presented in Table 1.The majority of the correct responses for questions on the different subdomains were less than average.Responses are presented in Table 2.The Pearson correlation coefficients for the scores on the seven subdomains of AD are presented in Table 5. High correlation coefficients were observed between the different scores, and these strong positive associations between the seven subdomains were also confirmed by the factor analysis where weights of the variables for the subdomains were significantly loaded on the same factor (factor 1) (Table 6).

Discussion
This research is among the first investigations of the population's knowledge in Saudi Arabia regarding AD based on the Polish ADKS.This study confirmed the findings of previous studies on the validity and reliability of this questionnaire [19][20][21].In the present study, all questions of the questionnaire were significantly associated, as proven by the factor analysis and Cronbach's alpha of 0.911.Significant associations between the seven subdomains were found in this study.Life impact was found to be associated with caregiving, symptoms, and treatment.Moreover, risk factors, assessment and diagnosis, caregiving, and management and treatment were found to be associated with the course of AD.As the intervention for AD is multidisciplinary, it is worth noting that the well-being of the patient is directly influenced by these factors [22].Increased educational levels had lower scores on the subdomains of risk factors and life impact.This is contradictory to the findings of other studies [23][24][25].Female participants had less retention of knowledge on life impact, caregiving, treatment and management, risk factors, and course than males.On the other hand, males had higher scores on the subdomains of assessment and diagnosis.This is not in line with other studies [26,27].Previous studies found that advancing age and postgraduate training were significantly associated with better information on knowledge about AD [26,28].However, in this study, we did not find such an association.Meanwhile, it was shown in the present study that higher knowledge on the course subdomain was associated with having relatives diagnosed with AD, which could be related to gaining knowledge through their experience with their affected relatives.Previous studies found similar associations [5,18].The factor analysis employed in this study revealed that all elements of the seven subdomains of knowledge score about AD were significantly related; thus, identifying the knowledge gap is crucial to bridge the gap in knowledge of the public about AD.Symptoms were found to be associated with treatment and management.As AD is managed by multiple specialties, integration of these subdomains is essential for the well-being of the patient [29].Lack of knowledge on caregiving may to some extent delay the management and interventions provided to patients diagnosed with AD and lead to adverse effects on their quality of life [30].

Limitations
There are some limitations of this study.As this study was cross-sectional, and the sampling technique was a non-probability convenient one, its generalization to the population may be limited; however, this study was an exploratory investigation.

Conclusions
In this study, the majority of studied participants had a lower level of knowledge on all domains of knowledge about AD.All subdomains of knowledge about AD were significantly correlated and potentiated each other.Upgrading the knowledge of the public about these subdomains will improve the management of AD, with subsequent improvement in the quality of life of affected individuals.Thus, national awareness campaigns for all parts of the community are essential to enhance awareness about AD.

TABLE 1 : Frequencies of variables.
2023 El-Gamal et al.Cureus 15(12): e50188.DOI 10.7759/cureus.501883 of 12 Question for each subdomain Correct answers (%) Life impact People with AD are particularly prone to depression 41.3%Most people with AD live in nursing homes 10.8%It is safe for people with AD to drive as long as they have a companion in the car at

TABLE 2 : Distribution of the participants according to the correct answers to the questions on the different domains of
Alzheimer's disease (AD).The maximum score for each subdomain and the mean score for the different categories of the sociodemographic variables are displayed in Table3 and

Table 4 .
Slight variations in the mean scores of the different categories of the sociodemographic variables were noticed.In general, the mean scores for the knowledge of the population on the subdomains of AD were substandard.

Variables Weight of variables on Factor 1
People with AD are particularly prone to depression 0.502It has been scientifically proven that mental exercises can prevent a person from getting AD 0.127 When a person with AD becomes agitated, a medical examination might reveal other health problems that caused the